Intake

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Intake Form
Please provide us with information about your child's family and household, health, development, education, private service (non-school), and problem behavior.  What you share in this Intake Form helps us to better serve you and your family.
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* Indicates required question
Email *
Your email
Who referred you?
Your answer
Child First and Last Name *
Your answer
Child Date of Birth *
MM
/
DD
/
YYYY
Diagnoses, Diagnosing Physician*, and Date of Each Diagnosis
If you intend us to bill insurance, we need record of the diagnosing doctor and the date of each diagnosis. Emailing documentation like diagnostic paperwork or assessment reports may be necessary for securing pre-authorization with insurance
Your answer
Describe the concerns you have about your child's current skills and developmental history. *
Your answer
Language(s) Spoken in Household *
Your answer
Language(s) Spoken by Child *
Your answer
Child lives with: *
Address *
Your answer
Gate Code
Your answer
Sibling Name(s) and Age(s)
Your answer
List any special needs or concerns regarding the other children living in your home.
Your answer
Parent/Guardian 1 - Name, Phone Number, and Email *
Your answer
Parent/Guardian 2 - Name, Phone Number, and Email
Your answer
Describe any parent training you've received or any experience you have with ABA, special education, or pediatric therapy. *
Your answer
Please outline any family and household circumstances that may affect your child's progress, behavior, or development (e.g., health issues, divorce, separation, foster siblings, death, frequent travel, variable or extended work schedule, frequent arguing, etc.).
Your answer
Has your child ever been under the care of an au pair, nanny, or other long-term caregiver other than a parent or guardian? *
If yes, how many total caregivers has your child had and how long was your child under the care of each caregiver (month/year-month/year)?
Your answer
Has your child ever attended a home or center-based daycare? *
If yes, list the daycares and the time periods during which your child attended each daycare (Month/Year-Month/Year).
Your answer
Was your child adopted? *
If your child was adopted, how old was he/she when they joined your family?
Your answer
Describe any complications experienced during the pregnancy.
Your answer
Was the child born full term (38-42 weeks)?
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If no, what was the duration of the pregnancy?
How many weeks?
Your answer
List any operations, serious illnesses, injuries, hospitalizations, allergies, or other special conditions your child has had since birth.
Your answer
Describe any dietary restrictions or special diet your child adheres to.
Your answer
List any medications your child has taken long term (3 months or more), medications your child is currently taking, dosage levels, and dates medications began and were discontinued.
Your answer
How many hours of sleep does your child get each night? *
Does your child routinely sleep through the night? *
Does your child routinely take naps? *
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